Healthcare Provider Details

I. General information

NPI: 1699929927
Provider Name (Legal Business Name): GERALDINE R JANUARY RN, PMHCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 E LOHMAN AVE
LAS CRUCES NM
88001-3172
US

IV. Provider business mailing address

PO BOX 168
RADIUM SPRINGS NM
88054-0168
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-6867
  • Fax:
Mailing address:
  • Phone: 575-202-0344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR58219
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: